All sections must be completed.
If you have answered 'YES' to either of these questions, do not use this form.
Instead, please call Quality Assurance at 1-312-997-9980
Select original mask placed on patient (please check appropriate box):
Full Face Masks
What mask did you provide as a replacement?
Please return masks if still available to the following address:
Sunset Healthcare Solutions
279 Madsen Dr #101
Bloomingdale, IL 60108
Please allow 14 business day for processing (includes delivery time), but may take longer if item is unavailable.